Provider Demographics
NPI:1679526446
Name:SHOPKO STORES OPERATING CO LLC
Entity type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR. VICE PRESIDENT HEALTH SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:BETTIGA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:920-429-4297
Mailing Address - Street 1:1370 US HIGHWAY 2 E
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3221
Mailing Address - Country:US
Mailing Address - Phone:406-257-1274
Mailing Address - Fax:406-257-1268
Practice Address - Street 1:1370 US HIGHWAY 2 E
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3221
Practice Address - Country:US
Practice Address - Phone:406-257-1274
Practice Address - Fax:406-257-1268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332H00000X
MT11963336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
2705424OtherNCPDP NUMBER
MT5607901Medicaid
MT0220844Medicaid
MT5604924Medicaid
MT0230418Medicaid
MT011002736Medicare PIN
2705424OtherNCPDP NUMBER
5695760119Medicare NSC